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Home My WebLink About0071 GOSNOLD STREET �7 � C�s�--�� Town of Barnstable *Permit# Regulatory Services Expires 6monthsis elate snxrvsrxa[.�. 9 pass. Thomas F.Geiler,Director ®, t�MA'tA Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY GNot Valid without Red X-Press Imprint (10 Map/parcel Number 1 Property Address loe ❑ Residential Value of Work � ��0� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Addresses YU,� )l Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ® ® 'T Check one: ❑ I am a sole proprietor MAY - 7 2012 I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name `SOWN OF BARNSTABLE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to y Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. y SIGNATURE• Q:IWPFlLES\FORMS\building permit forms\EXPRESS.doC Revised 051811 The Commonwealth of Massackusetts arftwit of lndustrial Accidaws 57 Office of Investigations 600 Washington,Street Boston,M54.1121I1 wmst mass grwldia Workers' Compensation Insurance Affidavit Bm2der-dContractursnEIectrk ans/Plumbers Applicant Information - Please Print Lemb}y Na ei. �GitylState(�ip -� ,C S Phone 4-7 Are you an employer? eckthe appropriate boa: T of project r 4. I am a ctmtractar and i }'Pe P I (required): 1.❑ I am a employer with ❑ � 6- ❑New construction employees(M and/or part-time)-* have hied the sub-contractors 2.❑ I am a sole proprietor or parker- Iisted on the attached sheet. 7- ❑Remodeling slap and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have workers' [No workers'camp:insurance camp•insurance l 9- ❑Building addition 4�ed] 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions -0 I am a homeowner doing all work of oers have exercised their 11.[_]Plumbing repairs or additions myself[No worlmrs'camp. fight of exemption per MGL insurance required]T c.152, §1(4),and we have no 12.❑Roof repairs employees-[No workers' 13-❑Other comp-insurance required-] "Any apprvc,=that checks box#1 mast also fal out the section below showing their u adere congmsationpolic9 infomMatian_ i Fiamoeowners who submit this affi&ngt indicating they we doing all wa l and then hire outside contractors must submit a new affidavit in&catmg such_ ICoutractors that t heclt this box mtest muched s n additional sheet showing the name of the sub-conftwA s and:stste whetle arucrt those entities have employees. If the snb•contmctots bave employees,they must provide their markers'comp.policy ntnaber- lain an employer that is pr vfi ing workers'congmsadon.insurance far sty empkq we& Below is the poUcy and jab site information. Insurance Company Name: Policy#or Self-ins.11c.4: Expiration Date: Job Site Address: City/State zip: I Attach a copy of the workers'compensation policy declaration page(showing the policy.number and expiration date). Failure to secure coverage as requred under Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250M a day against the violates- Be advised that a copy of this stated maybe ft vnwded to the Office of Investigations of the DIA for insi trance coverage verification. I da hereby c ' under the pains and allies ofpedwy�that the information prm i&d above is true and correct r—Datef-7 Phone;#L�J,�o � � C�ca✓� 0, dal use only. Do not amide in thin area,to be completed by city or town official City or Town: ;. PermitUceme If Lnuing Authority(drde one): 1.Board of Health 2.Bading Department 3.City(rawn Clerk 4.Electrical Inspector S.Plumbing Inspector 6.tither Coatact Person: Phone 9: 6 G; s;. Town of Barnstable Regulatory Services Z 14 ram $,` Thomas F.Geiler,Director 1659- ♦� '°�cMora Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DA 1--4 �►p� //�� r/ JOB-LOCATION: /� L%dS �� G�vZ C� `number street '�— village �1A '�� name L home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection proceduAes and requirements and that he/she will comply with said procedures and requirements. i gnatwe_of Homeowner i .—, '_,__..;; Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building-Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION - The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as"supervisor." Many homeowners who.use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. r To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 oFtNE • IARNSTA1314 • 3 .� Town of Barnstable 9. Regulatory Services Thomas F.Geiler,Director Building:Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 - ' '`~ Fax: 508-790-6230 Property Owner`Must , `Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit;please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMSUilding permit formslEXPRESS.doc Revised 051811